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SAKJOAQUIN <br />COUNTY- Environmental Health Department <br />-- <br />Monitoring Well/Soil Boring Inspection Report <br />Date: —,- �Inspector: i'r t CONSTRUCTION <br />Facility A dti rens: PA fi <br />Well Address: _ Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: `1, Min 2" Annular EHD Seal Verified: ❑Yes El No <br />Drilling Company: <br />Driller Onsite: Screen Length From: To: <br />Consultant: kM&L L Filter Pack From: To: <br />Geologist: `CCI y QV\ Bentonite From: To: <br />Grout From: To: <br />Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes El No <br />If yes, location and distance: <br />CAMPI Inlr <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth:> <br />Depth to Water: <br />Grout Material: W tk' �1 ►mow <br />Gallons of Grout Used: ^-- -P S�fS <br />❑Well Installation []Well Destruction <br />❑Boring Installation Boring Destruction <br />MFTWnn I IcFn I <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity-4Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />eallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />NBags <br />Thickest Thinnest <br />"Bags <br />2.5 5 <br />1 <br />5 <br />10 <br />1 <br />5 10 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />25 <br />s0 <br />5 <br />15 30 <br />6 <br />30 <br />60 <br />6 <br />5 35 <br />7 <br />35 <br />70 <br />7 <br />2 40 <br />tZQ <br />40 <br />80 <br />8 <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s*cehd.com <br />